Cost effectiveness of routine histology for haemorrhoidectomy specimens

Background: Routine histology for haemorrhoidectomy specimens remains commonplace in clinical practice, as a method of detecting incidental anal cancer. However, its utility and cost-effectiveness is unclear in the literature. This study aimed to determine the cost-effectiveness of routine histology for haemorrhoidectomy specimens in a regional Australian hospital. The secondary aim was to determine the proportion of specimens sent for histology, and whether individual surgeons had a statistically significant preference for whether to send for histology.Methods: This was a retrospective cohort study of patients who received haemorrhoidectomies at Hervey Bay Hospital between March 2012 and May 2020. Cost effectiveness of routine histology was investigated by weighing the number of incidental anal cancers detected against the cost of analysis. The proportion sent for histology was determined, both as a whole and by individual consultant surgeons.Results: Routine histology was ordered in 65% of patients who received haemorrhoidectomies over the study period (n=119), costing $13,623 AUD ($1,651 AUD per year). No cases of incidental anal dysplasia or neoplasia were found. Only 1 of the 8 most prolific surgeons over the study period demonstrated a statistically significant preference for whether to send for histology.Conclusions: Our study does not support routine histology for haemorrhoidectomy specimens as a cost-effective practice for detecting incidental anal cancer. Most individual surgeons did not display a clear preference for whether to send for histology.

Emergency Department Utilisation by Palliative Patients in a Regional Australian Setting

Background: Many palliative care patients attend emergency departments (EDs) in acute Hospital. However, very limited studies inform about their presentations and appropriateness. Objectives: This study explored the reasons and appropriateness of palliative care presentations in a regional Australian ED setting. Methods: A retrospective, single-centre observational study was conducted in a regional Australian hospital. All patients between January and December 2018 known to palliative care services presented to ED were included. Appropriateness of presentations was determined based on urgency of tests and treatments received, and practicability of obtaining these in a different setting. Results: A total of 35 patients made 85 presentations to the ED in 2018. The most common individual presenting complaints were shortness of breath (18.9%) followed by pain (14.1%), fever (11.8%), fall (8.2%), reduced oral intake or dehydration (8.2%), and bleeding (8.2%). The patients were brought by an ambulance in 56.5% presentations, and 63.5% presentations were admitted. About 93% presentations were referred by community healthcare professionals or required urgent investigation or management. Conclusions: This study found the majority of presentations were appropriate since their management could not be delivered at other primary care settings. This study adds value to the growing body of evidence and supports future multi-site longitudinal studies.

Institutional governance and responsiveness to antimicrobial resistance: a qualitative study of Australian hospital executives

ObjectivesDespite escalating antimicrobial resistance (AMR), implementing effective antimicrobial optimisation within healthcare settings has been hampered by institutional impediments. This study sought to examine, from a hospital management and governance perspective, why healthcare providers may find it challenging to enact changes needed to address rising AMR.DesignSemistructured qualitative interviews around their experiences of antimicrobial stewardship (AMS) and responsiveness to the requirement for optimisation. Data were analysed using the framework approach.SettingTwo metropolitan tertiary-referral hospitals in Australia.ParticipantsTwenty hospital managers and executives from the organisational level of department head and above, spanning a range of professional backgrounds and in both clinical and non-clinical roles, and different professional streams were represented.ResultsThematic analysis demonstrated three key domains which managers and executives describe, and which might function to delimit institutional responsiveness to present and future AMR solutions. First, the primacy of ‘political’ priorities. AMR was perceived as a secondary priority, overshadowed by political priorities determined beyond the hospital by state health departments/ministries and election cycles. Second, the limits of accreditation as a mechanism for change. Hospital accreditation processes and regulatory structures were not sufficient to induce efficacious AMS. Third, a culture of acute problem ‘solving’ rather than future proofing. A culture of reactivity was described across government and healthcare institutions, precluding longer term objectives, like addressing the AMR crisis.ConclusionThere are dynamics between political and health service institutions, as well as enduring governance norms, that may significantly shape capacity to enact AMS and respond to AMR. Until these issues are addressed, and the field moves beyond individual behaviour modification models, antimicrobial misuse will likely continue, and stewardship is likely to have a limited impact.

Australian hospital staff perceptions of barriers and enablers of domestic and family violence screening and response

Background Hospital presentations provide unique opportunities to detect DFV. However, up to 70% of women experiencing Domestic and Family Violence (DFV) go undetected by hospital staff. While routine DFV screening is internationally encouraged, there is still much debate surrounding its implementation. The aim of the study was to determine staff perceptions of barriers and enablers of DFV screening and response. Methods A cross-sectional survey was conducted at a tertiary level public hospital and health service. Health care staff in allied health, maternity and mental health divisions (n = 615) were invited to participate by email and through team meetings. 172 responses were analysed. Results Less than a third of respondents reported routinely asking patients about DFV, with 34.9% reporting they did not have sufficient training to assist with DFV. Increased levels of training were positively correlated with screening practices, preparedness and knowledge. Major barriers were presence of partner and language barriers, while written protocols and supportive work environment were the principal enablers of screening. Conclusion Staff generally believed that routine screening was important and should encompass all forms of abuse. Many felt ill-equipped to ask about or manage disclosure of DFV. More training improves staff capacity for DFV detection and response, and written guidelines should be made available to all staff.

EP.TU.373What We Do In The Shadows: Night Surgical Registrars and Abdominal Pain

Aim Surgical cover at night differ according to hospitals and are often performed by junior registrars. This can be challenging as a certain amount of independence is required in decision making. Abdominal pain remains one of the most common surgical presentations in the Emergency Department. This study analyses the type of abdominal pain presentations that were reviewed overnight in a regional Australian hospital. Method All patient presentations requiring surgical review from 9.00pm to 7.00am over a period of 4 months are prospectively collected and analysed. Patient details collected comprised of gender, date of review, blood tests, imaging results, histopathology, and intra-operative findings. Results Of the 114 patients who presented with abdominal pain, the majority of them were undifferentiated abdominal pain (n = 20, 17.1%). This is then followed by appendicitis (n = 17, 14.5%), diverticulitis (n = 13, 11.1%), pancreatitis (n = 8, 6.8%) and cholecystitis (n = 6, 5.1%). Among the others, a total of 8 presentations required urgent surgical review which resulted in three emergency surgeries being performed overnight, a laparotomy for closed loop small bowel obstruction, a Hartmann's procedure and a laparoscopic appendicectomy on a septic patient. Conclusion Common presentations for abdominal pain overnight include undifferentiated abdominal pain, appendicitis, diverticulitis, cholecystitis and pancreatitis. Hence education for night surgical registrars should be focused on management of these common conditions and also on surgical emergencies such as closed loop bowel obstructions, septic patients and perforated viscus to ensure optimal patient outcome without the need for close supervision.